In the United States Court of Federal Claims 

OFFICE OF SPECIAL MASTERS

No. 17-830V

Filed: January 31, 2019

UNPUBLISHED

DEANNA WILLIAMS,

 Petitioner,

v.

SECRETARY OF HEALTH AND 

HUMAN SERVICES,

 Respondent.

Special Processing Unit (SPU); Fact 

Ruling; Ruling on Entitlement; Table 

Injury; Influenza (Flu) Vaccine; 

Shoulder Injury Related to Vaccine 

Administration (SIRVA)

Shealene Priscilla Wasserman, Muller Brazil, LLP, Dresher, PA, for petitioner.

Ryan Daniel Pyles, U.S. Department of Justice, Washington, DC, for respondent.

FINDING OF FACT AND RULING ON ENTITLEMENT1

Dorsey, Chief Special Master:

On June 20, 2017, petitioner filed a petition for compensation under the National 

Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.,

2

(the “Vaccine 

Act”). Petitioner alleges that she suffered a shoulder injury related to vaccine 

administration (“SIRVA”) as a result of her October 22, 2014 Influenza (“flu”) 

vaccination. Petition at 1-2. The case was assigned to the Special Processing Unit of 

the Office of Special Masters. For the reasons described below, the undersigned finds 

that petitioner is entitled to compensation. 

 

1 The undersigned intends to post this decision on the United States Court of Federal Claims' website. 

This means the decision will be available to anyone with access to the internet. In accordance with 

Vaccine Rule 18(b), petitioner has 14 days to identify and move to redact medical or other information, 

the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, the 

undersigned agrees that the identified material fits within this definition, the undersigned will redact such 

material from public access. Because this unpublished decision contains a reasoned explanation for the 

action in this case, undersigned is required to post it on the United States Court of Federal Claims' 

website in accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal 

Management and Promotion of Electronic Government Services).

2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for 

ease of citation, all “§” references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. § 

300aa (2012).
2

I. Procedural History

In the petition filed on June 20, 2017, Ms. Williams asserted that she sustained a 

left shoulder injury resulting from a flu vaccination on October 22, 2014. Petition at 1. 

In support of her petition, Ms. Williams filed medical records (Exs. 1-3) and an affidavit 

(Ex. 4). ECF No. 1. During the initial status conference held on July 24, 2017, 

petitioner agreed to file any outstanding medical records and any additional records 

documenting her October 22, 2014 vaccination. ECF No. 9. Petitioner also agreed to 

file an affidavit addressing her delay in seeking treatment for her left shoulder pain and 

explaining why she did not report her shoulder pain at a February 25, 2015 visit to her 

primary care provider. Id. 

Petitioner subsequently filed additional medical records (Ex. 5) and a detailed 

affidavit (Ex. 6). ECF Nos. 11-12. Petitioner confirmed that no additional vaccination 

records were filed. See Informal Communication (Remark) filed October 20, 2017. In 

October and November 2017, petitioner filed additional affidavits from Stefan Fujczak, 

Daniel Torres, and Cindy Garcia (Exs. 7-9). ECF Nos. 15-17. 

On January 5, 2018, respondent filed a status report noting that petitioner had 

not filed additional documentation regarding her vaccine administration. ECF No. 20. 

Respondent requested a January 23, 2018 deadline to file a Rule 4(c) Report and 

indicated that he would not entertain settlement on the current record. Id. 

Respondent filed his Rule 4(c) Report on January 19, 2018. ECF No. 21. In 

respondent’s view, petitioner had provided insufficient proof of vaccine administration. 

Id. at 3. Respondent further argued that, even if petitioner received a flu vaccination on 

October 22, 2014, she still had not established entitlement to compensation. Id. at 4. 

Specifically, respondent contended that there were “insufficient records substantiating 

that the onset of petitioner’s left shoulder symptoms began within forty-eight hours of 

vaccination” and a lack of documentation as to the site of vaccination. Id. 

At a status conference held on February 8, 2018, the parties indicated that they 

were amenable to conducting a fact hearing to resolve the issues regarding petitioner’s 

alleged October 22, 2014 flu vaccine administration and the onset of her shoulder injury. 

ECF No. 24. 

On March 1, 2018, the undersigned scheduled a fact hearing for April 17, 2018, 

in Washington, D.C., and stipulated that petitioner and her counsel would participate via 

video conference. Id. In an e-mail dated March 1, 2018, respondent indicated that he 

did not plan to call any witnesses. See Informal Communication (Remark) filed March 

12, 2018. Petitioner indicated on March 21, 2018 that she would testify at the hearing 
3

but did not plan to call any other witnesses. ECF No. 26. Petitioner also filed an 

affidavit from Winona Henebry on March 21, 2018 (Ex. 10). ECF No. 27. 

A fact hearing was held on April 17, 2018. See Minute Entry filed April 17, 2018. 

In a scheduling order filed April 19, 2018, petitioner was ordered to file a complete set of

orthopedic and physical therapy records, petitioner’s pain diary, and a status report 

indicating the date by which petitioner anticipated providing a letter regarding the 

amount of her Medicaid lien. ECF No. 28. 

Petitioner filed her pain diary (Ex. 11) on April 23, 2018. ECF No. 29. Petitioner 

filed additional physical therapy records (Ex. 12) on July 19, 2018. ECF No. 38. 

Petitioner filed updated orthopedic records (Ex. 13) and an amended Statement of 

Completion on August 20, 2018. ECF Nos. 40-41. 

On October 30, 2018, the undersigned filed a scheduling order noting petitioner 

filed a Statement of Completion indicating that she beieved all of the relevant medical 

records have been submitted. ECF No. 42. The scheduling order informed the parties 

that the undersigned anticipated issuing a ruling on whether petitioner is entitled to 

compensation in this case. Id. The undersigned granted the parties until November 30, 

2018 to file any further evidence in regard to petitioner’s entitlement to compensation. 

Id. No additional evidence was filed.

II. Relevant Factual History

On October 22, 2014, petitioner presented for an appointment at her primary 

care provider. Ex. 1 at 25. She was noted to have a history of diabetes, 

musculoskeletal pain involving the right ankle, and snoring with associated sleep apnea, 

excessive fatigue, and daytime somnolence. Id. The office visit record reflects an entry 

of “Influenza, seasonal, injectable” under the “Orders” section of the record. Id. at 29. 

On November 19, 2014, petitioner returned to her primary care provider for lab 

work.3 Ex. 5 at 95. The associated treatment record does not contain an entry for a 

shoulder condition under the “Problem List” section, but documents entries for 

petitioner’s preexisting conditions, including obesity, asthma, left knee pain, snoring, 

diabetes mellitus, herpes-simplex virus 2 infection, and degenerative joint disease 

involving multiple joints. Id. 

On February 25, 2015, petitioner presented for a follow-up diabetes appointment 

at her primary care provider.

4

 Ex. 1 at 17. The “Review of Systems” section of the 

 

3 Petitioner presented to her primary care provider again on March 11, 2015 for lab work. Ex. 5 at 107. 

The associated treatment record lists the purpose of the visit as “Lab only” and does not contain sections 

for petitioner’s current medical complaints, review of systems, or physical examination. Id. 

4 Approximately two weeks prior to this appointment, petitioner presented for a diabetic screening 

appointment with an optometrist at Santa Clara Valley Medical Center Eye Clinic. Ex. 2 at 1. The 

associated medical record reflects complaints of blurry vision; however, petitioner was observed to have a 

normal visual examination. Id. 
4

treatment record contains an entry of “Negative” for musculoskeletal complaints. Id. at 

19. On examination, the physician observed that a visual overview of petitioner’s

extremities was normal. Id. at 20. 

On March 17, 2015, petitioner presented for an evaluation of possible obstructive 

sleep apnea at HHS Santa Clara Valley Medical Center. Ex. 2 at 1-5. The progress 

note does not reflect any complaints of shoulder symptoms. Id. On examination, 

petitioner was observed to appear “well” and in no distress. Id. at 4. 

On March 19, 2015, petitioner presented for a follow-up lab and diabetes 

appointment at her primary care provider. Ex. 5 at 112. The associated treatment 

record does not contain an entry for a shoulder condition under the “Problem List” 

section. Id. The “Review of Systems” section contains an entry of “Negative” for 

musculoskeletal complaints. Id. at 114.

On April 6, 2015, petitioner presented at her primary care provider with 

complaints of musculoskeletal pain and spasms. Ex. 1 at 10. Petitioner specifically 

reported that she had experienced “left shoulder pain that [had] become progressively 

worse since receiving [a] flu shot at the end of October.” Id. Petitioner explained that 

her pain affected her left dominant extremity and described her symptoms as worsening 

with lifting. Id. On examination, petitioner was observed to have left shoulder 

tenderness, pain with lifting her arm over her head, and pain with rotation of her arm. 

Id. at 13. The physician assistant assessed petitioner with “left shoulder pain” and 

suggested an over-the-counter NSAID for pain relief. Id. Additionally, petitioner was 

referred for an MRI of her left shoulder. Id. 

A June 1, 2015 MRI of petitioner’s left shoulder revealed “moderate to severe 

tendinosis of the supraspinatus, infraspinatus, and subscapularis tendons.” Ex. 5 at 

135. Other findings included “small” effusion, moderate to severe osteoarthritis of the 

acromioclavicular joint, and “small subacromial subdeltoid bursal fluid.” Id. The imaging 

report noted “[f]eatures which may indicate predisposition to subacromial impingement.” 

Id.

5

 

On July 17, 2015, petitioner returned to her primary care provider with complaints 

of left shoulder pain that had been ongoing for nine months. Ex. 1 at 4. She stated that 

she had experienced mild worsening since her last medical appointment and again 

reported increased pain with lifting. Id. On examination, petitioner presented with 

positive cross body testing, positive lift off testing, and abnormal strength testing. Id. at 

 

5

In SIRVA, “symptoms are thought to occur as a result of unintended injection of vaccine antigen or 

trauma from the needle into and around the underlying bursa of the shoulder resulting in an inflammatory 

reaction.” 42 C.F.R. § 100.3(c)(10). “SIRVA is caused by an injury to the musculoskeletal structures of 

the shoulder (e.g., tendons, ligaments, bursae, etc.).” Id. Petitioner’s June 2015 MRI findings appear to 

be consistent with an injury to the bursa caused by an intramuscular injection as reported by S. Atanasoff, 

et al., in Shoulder injury related to vaccine administration (SIRVA), 28 Vaccine 8049 (2010). 
5

7. Petitioner’s treating physician assessed her as having a “rotator cuff injury” and 

referred her for physical therapy and an orthopedic surgery consultation. Id. at 8. 

On October 6, 2015, petitioner was evaluated by an orthopedist at HHS Santa 

Clara Valley Medical Center. Ex. 2 at 11. At that time, petitioner complained of left 

shoulder pain that had lasted for one year and identified her pain as beginning after she 

received a flu shot. Id. Petitioner reported associated difficulty with performing

overhead activity and reaching. Id. Petitioner also complained of having pain at night, 

but noted that she experienced moderate symptom relief with over-the-counter NSAIDs. 

Id. On examination, petitioner presented with tenderness to palpation of the left 

shoulder, 170 degrees of flexion, 50 degrees of external rotation, mildly positive Neer’s 

and Hawkin’s testing, and normal strength. Id. The orthopedist diagnosed petitioner 

with left shoulder rotator cuff tendonitis and advised her to continue taking NSAIDs. Id. 

The orthopedist also referred petitioner for physical therapy and discussed adding 

injections to her course of treatment if her symptoms did not improve. Id. 

On October 27, 2015, petitioner presented for an initial evaluation at San Jose 

Physical Therapy. Ex. 3 at 1. She rated her pain as ranging from “4” to “7” out of “10” 

and reported that it worsened with lifting, carrying, and sleeping on her left side. Id. 

She added that her pain had limited her ability to perform work as a massage therapist. 

Id. Petitioner attended a total of seven physical therapy sessions from October 27, 

2015 through January 8, 2016. Id. at 1-30. In a discharge summary dated January 8, 

2016, petitioner was recorded as rating her pain as a “1” out of “10.” Id. at 28. She 

commented that she had experienced “perceived improvement” of 75%. Id. The 

physical therapist recorded improvement of petitioner’s left shoulder strength and range 

of motion. Id. Petitioner was discharged to an independent home exercise program. 

Id. at 30. 

On March 2, 2016, petitioner presented to her primary care provider for treatment 

of a genitourinary condition. Ex. 5 at 240. The associated medical record contains an 

entry of “Influenza, seasonal, injectable” with a “date given” of October 22, 2014 under 

the “Immunization History” section of the record. Id. at 243. 

On September 20, 2016, petitioner returned to her primary care provider for a 

follow-up appointment regarding her musculoskeletal pain. Id. at 431. She again 

reported that she “started having the left shoulder pain after receiving the flu vaccine in 

2014.” Id. On examination, petitioner presented with tenderness of the left shoulder 

with positive cross body and lift off testing. Id. at 434. Petitioner’s treating physician 

assessed tendinopathy of the rotator cuff and referred her for an orthopedic surgical 

consultation. Id. at 435. 

On December 8, 2016, petitioner was evaluated by an orthopedist at HHS Santa 

Clara Valley Medical Center. Ex. 13 at 2-3. Petitioner reported that she had been 

experiencing left shoulder pain for two years that had started after she received a flu 

shot. Id. at 3. Petitioner was administered an epidural steroid injection. Id. 
6

On February 28, 2017, petitioner presented to her primary care provider for 

treatment of a genitourinary condition. Ex. 5 at 414. The associated record contains an 

entry of “Influenza, seasonal, injectable” with a “date given” of October 22, 2014 under 

the “Immunizations History” section of the record. Id. at 419. 

On March 13, 2017, petitioner presented for a follow-up shoulder appointment 

with her primary care provider. Id. at 443. At that time, petitioner noted that her left 

shoulder symptoms had improved following an injection in December 2016; however, 

she indicated that her pain had subsequently returned. Id. Petitioner added that she 

believed her shoulder pain was caused by a flu shot she received in 2014. Id. 

Petitioner inquired whether she could return for further orthopedic treatment. Id. The 

physician assistant indicated that she would seek information regarding whether a new 

referral was necessary. Id. at 445. The available record does not contain evidence of 

further medical treatment related to petitioner’s alleged shoulder injury. 

III. Affidavits Filed by Petitioner

On June 20, 2017, petitioner filed an affidavit pursuant to § 11(c)(1). Ex. 4. In 

her affidavit, petitioner asserted that she suffered a left shoulder injury caused by the flu

vaccine she received on October 22, 2014. Id. at ¶¶2-4. Petitioner averred that she 

suffered the residual effects of her injury for more than six months and had not received 

an award or settlement for the injury. Id. at ¶¶4-5.

On September 29, 2017, petitioner filed a more detailed affidavit. Ex. 6. She 

again averred that she was administered a flu vaccine in her left shoulder on October 

22, 2014. Ex. 6 at ¶2. Following the vaccination, petitioner noted that she immediately 

felt pain at the injection site. Id. at ¶3. She indicated that her pain continued over the 

subsequent months, “but did not become severe until the following spring.” Id. 

Petitioner averred that she informed her medical providers regarding her pain on 

November 19, 2014, February 25, 2015, and March 19, 2015; however, she alleged that 

these providers “did not believe [her] and dismissed [her] complaints.” Id. at ¶¶4-6. 

Petitioner noted that her reports of left shoulder symptoms were first taken seriously on 

April 6, 2015, at which time her medical provider ordered an MRI of her left shoulder. 

Id. at ¶7.

In October and November 2017, petitioner filed additional affidavits from Stefan 

Fujczak (her friend), Daniel Torres (her friend), and Cindy Garcia (her friend). Exs. 7-9. 

In his affidavit, Mr. Fujczak noted that, prior to her flu vaccination in October 2014, 

petitioner had “never complained of soreness, pain, or difficulty using her left arm or 

shoulder.” Ex. 7 at ¶4. Mr. Fujczak recounted an episode from October 2014 in which 

he was present at petitioner’s home and was asked by petitioner to carry a case of 

water up her stairs. Id. at ¶5. According to Mr. Fujczak, petitioner stated that she had 

received a flu shot and had soreness in the area of the vaccination. Id. Mr. Fujczak 

recalled that petitioner “would not stop complaining about her left arm being in pain 

because she was left handed.” Id. 
7

In his affidavit, Mr. Torres recounted an episode from a “few years ago” in which 

he was present at petitioner’s house to help her prepare for a home inspection. Ex. 8 at 

¶4. At that time, Mr. Torres observed that petitioner appeared to be in pain. Id.

According to Mr. Torres, petitioner told him that she was experiencing left upper 

extremity pain and had previously sought medical treatment; however, petitioner 

claimed that her medical provider “dismissed her complaints” and “did not believe her.” 

Id. at ¶5. Mr. Torres averred that petitioner had not previously “complained of pain or 

difficulty using her left arm or shoulder.” Id. at ¶7.

In her affidavit, Ms. Garcia recounted an episode from December 12, 2014 in 

which she and petitioner organized a birthday party for a mutual friend. Ex. 9 at ¶5. 

Ms. Garcia recalled that petitioner asked her to carry wine and groceries from her car 

due to petitioner’s shoulder pain. Id. During the party, Ms. Garcia observed that 

petitioner appeared “miserable.” Id. at ¶6. According to Ms. Garcia, petitioner 

explained that she was experiencing shoulder pain and eventually left early from the 

gathering. Id. Ms. Garcia noted that, prior to December 2014, petitioner had never 

complained of pain or difficulty using her left arm or shoulder. Id. at ¶4. 

On March 21, 2018, petitioner filed an affidavit from Winona Henebry, her friend. 

Ex. 10. Ms. Henebry averred that she spoke with petitioner by phone on October 23, 

2014. Id. at ¶5. Ms. Henebry explained that she remembered the specific date 

because she recalled speaking to petitioner a few days prior to her October 25, 2014

birthday to make plans. Id. During the call, Ms. Henebry recounted that petitioner told 

her she had been administered a flu shot and was experiencing left arm pain. Id. Ms. 

Henebry averred that petitioner continued to complain of left arm pain during her 

birthday dinner at Spaghetti Factory the following weekend. Id. at ¶6. Thereafter, Ms. 

Henebry noted that petitioner complained “all the time” about her pain. Id. at ¶7. Ms. 

Henebry recounted a specific conversation “around Thanksgiving” during which 

petitioner stated that her physician did not believe her regarding her complaints of left

arm pain. Id. Ms. Henebry noted that petitioner had not complained of pain or difficulty 

using her left arm or shoulder prior to October 22, 2014. Id. at ¶4. 

IV. Testimony by Petitioner

At the fact hearing held in Washington, D.C., on April 17, 2018, (see Transcript of 

Proceedings (“Tr.”) at ECF No. 33), petitioner provided testimony regarding her alleged 

October 22, 2014 vaccination, the onset of her injury, and her course of treatment. 

Petitioner explained that she was scheduled for a primary care appointment on 

October 22, 2014 to obtain approval for a gastric bypass surgery. Tr. at 8. During her 

appointment, petitioner testified that a nurse offered to administer a flu shot, which she 

accepted. Tr. at 9. Petitioner stated that the nurse appeared to administer the vaccine 

at a high location on her left upper extremity. Tr. at 9. 
8

Petitioner testified that she felt a sharp, throbbing pain immediately following her 

receipt of the flu vaccine. Tr. at 9-10. During the following days, she noted that the pain 

grew deeper and began to radiate from the site of injection downward through her arm. 

Tr. at 11. Petitioner testified that she reported her pain and other symptoms to her 

mother and Winona Henebry approximately one or two days following the vaccination. 

Tr. at 11-12. Thereafter, petitioner recounted that she experienced persistent pain until 

February or March 2015, at which point her symptoms worsened. Tr. at 13-14. 

Petitioner explained that, in addition to her preexisting symptoms, she began to 

experience spasms in her left upper extremity during these months. Tr. at 13-14. 

Petitioner testified that her left shoulder pain also affected her activities of daily living. 

Tr. at 12. Among other things, she noted that her shoulder injury necessitated 

assistance from her friends with housekeeping and carrying items up and down the 

stairs. Tr. at 12. 

Petitioner testified that she reported left shoulder symptoms to her medical 

providers prior to April 6, 2015—the date on which her medical records first reflect 

complaints of shoulder pain. Tr. at 14-17. Specifically, petitioner indicated that she 

complained of left shoulder symptoms at medical appointments on November 19, 2014, 

February 25, 2015, and March 19, 2015. Tr. at 14-17. In general, petitioner testified 

that her medical providers dismissed her complaints during those appointments and did 

not follow up with further examinations. Tr. at 14-17. Petitioner noted that she probably 

did not reference her shoulder condition other than in passing at a sleep clinic 

evaluation on March 17, 2015 because her shoulder symptoms did not have any 

bearing on the medical issue at hand. Tr. at 17-18. 

Petitioner testified that she did not seek urgent or emergency care following her 

vaccination because she underestimated the severity of her injury. Tr. at 18. She 

explained that she eventually sought specific treatment for her left shoulder on April 6, 

2015 because her pain had started to worsen and she was beginning to experience 

spasms. Tr. at 18. Petitioner also noted that, at prior medical appointments, she was 

told that she needed to make a specific appointment for her left shoulder pain in order to 

receive dedicated treatment for that condition. Tr. at 18-19. 

V. Respondent’s Opposition

Respondent filed a Rule 4(c) Report on January 19, 2018. See Respondent Rule 

4(c) Report (“Res. Report”), filed January 19, 2018 (ECF No. 21). Initially, respondent 

argues that petitioner has not established proof of vaccination. Id. at 3-4. Respondent 

notes that petitioner was previously ordered to file a more detailed vaccination record 

but failed to provide additional evidence. Id. As a result, respondent contends that the 

“proof of vaccine administration is insufficient on the current record.” Id. at 3. 

Respondent further argues that, even if the site of vaccination could be 

established, petitioner has not provided sufficient evidence to support her SIRVA claim. 

Id. at 4-5. Respondent specifically contends that “in addition to a lack of documentation 
9

of the site of vaccination” there are insufficient records to substantiate that the onset of 

petitioner’s left shoulder symptoms began within 48 hours of vaccination. Id. at 4. 

Respondent notes that petitioner’s medical records reflect four medical encounters in 

the months after her alleged vaccination that do not reference shoulder complaints. Id. 

at 4-5. Respondent asserts that petitioner first attributed her shoulder pain to the 

vaccination five-and-a-half months after the alleged vaccination. Id. at 5. Given the 

aforementioned issues, respondent requests that this case be dismissed. Id. 

VI. Findings of Fact

Before ruling on entitlement in this case, the undersigned must make the 

following factual determinations: (1) whether petitioner was administered an influenza 

vaccine on October 22, 2014 in her injured left arm and (2) whether petitioner’s shoulder 

symptoms began within 48 hours of her alleged vaccination. 

When making these factual findings, the undersigned adheres to the 

preponderance of evidence standard as set forth in Section 13(a)(1)(A) of the Vaccine 

Act. Under that standard, the existence of a fact must be shown to be “more probable 

than its nonexistence.” In re Winship, 397 U.S. 358, 371 (1970) (Harlan, J., concurring). 

Pursuant to Section 13(b)(2) of the Vaccine Act, the undersigned may find that 

the first symptom or manifestation of onset of an injury described in a petition occurred 

within the time period described in the Vaccine Injury Table even though the occurrence 

of such symptom or manifestation was not recorded if such finding is otherwise 

supported by a preponderance of the evidence. 

A. Finding of Fact Regarding Receipt and Site of Flu Vaccination

Upon review of the entire record and consideration of the parties’ contentions, 

the undersigned finds that there is preponderant evidence that petitioner received a flu

vaccination on October 22, 2014 in her left shoulder. Contrary to respondent’s 

argument, petitioner has filed substantial evidence that a flu vaccine was administered 

in her left shoulder on that date. 

Initially, an office visit record from petitioner’s primary care provider dated

October 22, 2014 reflects an entry of “Influenza, seasonal, injectable” under the 

“Orders” section of the record. Ex. 1 at 29. As indicated above, subsequent records 

from petitioner’s primary care provider on March 2, 2016 and February 28, 2017 contain 

entries of “Influenza, seasonal, injectable” with a “date given” of October 22, 2014 under 

the “Immunization History” section of the records. Ex. 5 at 243, 419. Considered 

together, the aforementioned medical records reflect substantial evidence that petitioner 

received a flu vaccination on October 22, 2014.6 

 

6 The undersigned notes, however, that several prior decisions within this program have held that the fact 

of vaccination need not be supported by medical records or opinion pursuant to Section 13(a) of the 

Vaccine Act. See, e.g., Centmehaiey v. HHS, 32 Fed. Cl. 612, 621 (1995), aff’d 73 F.3d 381 (Fed. Cir. 
10

In addition, petitioner’s treatment records consistently attribute her left shoulder 

symptoms to a flu vaccination she received in October 2014. These medical records 

provide strong corroborating evidence that petitioner received a flu vaccination in her 

left shoulder on October 22, 2014. See, e.g., Parker v. HHS, No. 15-1331V, 2016 WL 

3443929 (Fed. Cl. Spec. Mstr. May 13, 2016) (finding that a vaccine record recording 

administration in the left arm was incorrect based primarily on petitioner’s consistent 

attribution of his right shoulder condition to his vaccination throughout his treatment). 

Notably, at petitioner’s medical appointment on April 6, 2015 in which she first received

dedicated treatment for her left shoulder symptoms, petitioner specifically reported that 

she had experienced “left shoulder pain that [had] become progressively worse since 

receiving [a] flu shot at the end of October.” Ex. 1 at 10. Thereafter, petitioner 

consistently attributed her left shoulder injury to a flu vaccination from the same period. 

See, e.g., Exs. 2 at 11; 5 at 431, 443; 13 at 3. 

The undersigned also found petitioner to be a highly credible witness whose 

testimony was corroborative of the aforementioned medical records regarding the date 

and location of her flu vaccination. Moreover, petitioner filed affidavits from her

acquaintances that credibly recount statements made by petitioner in the days and 

weeks after October 22, 2014 in which she linked her sudden-onset left shoulder 

symptoms to an earlier flu shot. Exs. 7 at ¶¶4-5; 10 at ¶¶4-5. Based on all of the 

above, the undersigned finds that there is preponderant evidence that petitioner 

received a flu vaccination on October 22, 2014 in her left shoulder.

B. Finding of Fact Regarding Onset 

Upon review of the entire record and consideration of the parties’ contentions, 

the undersigned finds that there is preponderant evidence that petitioner’s alleged 

shoulder symptoms occurred within 48 hours of petitioner’s October 22, 2014 flu 

vaccination. 

As described above, petitioner credibly testified at the fact hearing that she felt a 

sharp, throbbing pain immediately following her receipt of the flu vaccine on October 22, 

2014. Tr. at 9-10. During the following days, she noted that the pain grew deeper and 

began to radiate from the site of injection downward through her arm. Tr. at 11. 

Petitioner’s testimony is corroborated by her post-vaccination medical records. Indeed, 

at petitioner’s medical appointment on April 6, 2015, she specifically reported “left 

 

1995) (stating that “[t]he lack of contemporaneous, documentary proof of a vaccination, however, does 

not necessarily bar recovery.”); see also Wonish v. HHS, No. 90-667V, 1991 WL 83959, at *4. (Fed. Cl.

Spec. Mstr. May 6, 1991) (stating that “[v]accination is an event that in ordinary litigation could be 

established by lay testimony. Medical expertise is not typically required.”); Woodson v. HHS, No. 91-

263V, 1992 WL 59707, at *2. (Fed. Cl. Spec. Mstr. Mar. 5, 1992) (finding that “the petition should not be 

dismissed as a matter of law merely because there is no documentary evidence that the vaccination took 

place and [petitioner] is the only witness claiming personal knowledge of the vaccination. Her testimony 

on this point must be weighed in the context of the entire record.”). In any event, the undersigned has 

found medical records corroborating petitioner’s allegations.
11

shoulder pain that [had] become progressively worse since receiving [a] flu shot at the 

end of October.” Ex. 1 at 10. The undersigned finds this notation to be corroborating 

evidence that petitioner’s shoulder pain began on October 22, 2014 and worsened in 

the following months. At subsequent medical appointments, petitioner explicitly linked 

her left shoulder pain as beginning after her receipt of a flu vaccination. See, e.g., Exs. 

2 at 11; 5 at 431, 443; 13 at 3. 

Respondent notes that petitioner’s medical records reflect four intervening 

medical encounters between October 22, 2014 and April 6, 2015 that do not reference 

shoulder complaints.

7 Res. Report at 4-5. However, the undersigned finds that the 

relevant medical records, when reviewed in conjunction with petitioner’s testimony, 

provide a plausible and credible explanation for this omission. Initially, the undersigned 

notes that the medical record for petitioner’s November 19, 2014 appointment lists the 

purpose of the visit as “Lab only” and does not contain sections for petitioner’s current 

medical complaints, review of systems, or physical examination. Ex. 5 at 95. 

Furthermore, petitioner’s medical appointments on February 25, March 17, and March 

19, 2015 were for specific medical concerns unrelated to petitioner’s left shoulder 

condition. Exs. 1 at 17; 2 at 1-5; 5 at 112. 

Although the aforementioned treatment records do not contain any references to 

shoulder complaints, petitioner credibly testified that she did, in fact, report left shoulder 

symptoms to her medical providers on November 19, 2014, February 25, 2015, and 

March 19, 2015.8 Tr. at 14-17. Petitioner testified that her medical providers dismissed 

her complaints during those appointments and did not follow up with further 

examinations.9 Tr. at 14-17. In this case, the undersigned is persuaded that petitioner’s 

detailed testimony is in harmony with the contemporaneous records and provides 

additional credible statements regarding her condition that are absent or omitted from

the medical records. 

Finally, although petitioner did not seek dedicated treatment for her left shoulder 

injury until April 6, 2015—approximately five-and-a-half months following her October 

22, 2014 vaccination—the undersigned does not find the delay in treatment to be 

dispositive regarding the issue of onset. Indeed, as described above, petitioner testified 

that she did not seek urgent or emergency care following her vaccination because she 

underestimated the severity of her injury. Tr. at 18. She noted that she eventually 

 

7

In the “Facts” section of Respondent’s Rule 4(c) report, respondent specifically cites petitioner’s medical 

appointments on November 19, 2014 and February 25, March 17, and March 19, 2015. See Res. Report 

at 2. 

8 During the hearing, petitioner specifically testified that she probably did not reference her shoulder 

condition other than in passing at a sleep clinic evaluation on March 17, 2015 because her shoulder 

symptoms did not have any bearing on the medical issue at hand. Tr. at 17-18. 

9 As described above, Mr. Torres and Ms. Henebry also recounted in their affidavits that petitioner told 

them that her medical provider had dismissed her initial reports of left shoulder symptoms. See Exs. 8 at 

¶5; 10 at ¶7. 
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sought dedicated treatment for her left shoulder on April 6, 2015 because her pain had 

started to worsen and she had begun to experience spasms. Tr. at 18. Petitioner also 

explained that, at prior medical appointments, she was told that she needed to make a 

specific appointment for her left shoulder pain in order to receive dedicated treatment 

for that condition. Tr. at 18-19. In the undersigned’s experience, petitioner’s sworn 

testimony and medical records together reflect a pattern of treatment consistent with, 

and similar to, other SIRVA claims. 

In light of all of the above and in view of the record as a whole, the undersigned 

finds that there is preponderant evidence that petitioner’s alleged shoulder symptoms 

occurred within 48 hours of petitioner’s October 22, 2014 flu vaccination. 

VII. Ruling on Entitlement

In light of the above findings of fact, the undersigned further finds that this case is 

ripe for adjudication on the question of petitioner’s entitlement to compensation for her 

alleged SIRVA. For the reasons described below, the undersigned finds that petitioner 

is entitled to compensation.

A. Legal Standard

Effective for petitions filed beginning on March 21, 2017, SIRVA is an injury listed 

on the Vaccine Injury Table (“Table”). See Vaccine Injury Table: Qualifications and Aids 

To Interpretation. 42 C.F.R. § 100.3(c)(10). A vaccine recipient shall be considered to 

have suffered SIRVA if such recipient manifests all of the following: 

(i) No history of pain, inflammation or dysfunction of the affected shoulder prior to 

intramuscular vaccine administration that would explain the alleged signs, 

symptoms, examination findings, and/or diagnostic studies occurring after 

vaccine injection; (ii) Pain occurs within the specified time-frame; (iii) Pain and 

reduced range of motion are limited to the shoulder in which the intramuscular 

vaccine was administered; and (iv) No other condition or abnormality is present 

that would explain the patient's symptoms (e.g. NCS/EMG or clinical evidence of 

radiculopathy, brachial neuritis, mononeuropathies, or any other neuropathy). 

Id. The time period by which the symptomatology must begin is within 48 hours of 

vaccination. Id. at § 100.3(a)(XIV)(B). 

B. The Elements of Petitioner’s SIRVA Claim

The undersigned’s findings and conclusions are as follows: 

1. Petitioner did not have a history of pain, inflammation, or 

dysfunction of the affected shoulder prior to vaccine intramuscular 

administration 

The undersigned reviewed Ms. Williams’s medical history prior to her October 22, 

2014 flu vaccination. Petitioner did not have a history of pain, inflammation, or 
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dysfunction of her left shoulder prior to vaccination. Thus, petitioner satisfies this 

criterion. 

2. Onset occurred within the specified time frame

As described in Section (VI)(B) above, based upon the undersigned’s review of 

the entire record and consideration of the parties’ contentions, the undersigned finds 

that there is preponderant evidence that petitioner’s alleged shoulder symptoms

occurred within 48 hours of her October 22, 2014 flu vaccination. 

3. Pain and reduced range of motion were limited to the shoulder in 

which the intramuscular vaccine was administered

Petitioner reported on April 6, 2015 that she had experienced “left shoulder pain 

that [had] become progressively worse since receiving [a] flu shot at the end of 

October.” Ex. 1 at 10. Petitioner reported that her pain affected her left dominant 

extremity and described her symptoms as worsening with lifting. Id. On examination, 

petitioner was observed to have left shoulder tenderness, pain with lifting her arm over 

her head, and pain with rotation of her arm. Id. at 13.

Thereafter, as described above, petitioner reported left shoulder pain at multiple 

medical appointments. See, e.g., Exs. 1 at 4; 2 at 11; 3 at 1; 5 at 431, 443; 13 at 3. On 

several examinations, petitions was observed to have reduced range of motion of the 

left shoulder. See, e.g., Exs. 2 at 11; 5 at 198; 13 at 3. Based upon the undersigned’s 

review of the record, petitioner’s pain and reduced range of motion were limited to the 

left shoulder during the period at issue. 

4. No other condition or abnormality was present that would explain the 

patient’s symptoms (e.g. NCS/EMG or clinical evidence of 

radiculopathy, brachial neuritis, mononeuropathies, or any other 

neuropathy)

There is no evidence in the record that demonstrates any other type of condition 

or abnormality was present that would explain petitioner’s symptoms. 

C. Factors Unrelated to Vaccination

Respondent has not asserted, nor would the undersigned find, that there is any 

evidence in the record to support respondent’s burden of establishing an alternative 

cause for petitioner’s injury unrelated to vaccination.

VIII. Conclusion

In light of all of the above and in view of the record as a whole, the undersigned 

finds that (1) petitioner received an influenza vaccination in her left upper extremity on 

October 22, 2014; (2) the onset of petitioner’s left shoulder symptoms occurred within 

48 hours of vaccine administration; and (3) that petitioner has established the Table 

requirements for a SIRVA caused by her October 22, 2014 vaccination. For the 
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reasons described above, the undersigned finds that petitioner is entitled to 

compensation.

IT IS SO ORDERED.

s/Nora Beth Dorsey

Nora Beth Dorsey

Chief Special Master